What are the key concepts of mandatory public reporting of hospital acquired infections?

Mandates for public reporting of healthcare associated infections (HAIs) in the US have been primarily determined by state legislative bodies. Over the past decade, the majority of states have enacted laws to require reporting of HAIs. However, each state has independently developed its legislation, which has lead to a variety of approaches.More recently, some infections have become reportable as a condition of participation in the Medicare program.

Increasingly, states have mandated that hospitals report their HAIs through CDC's National Healthcare Safety Network (NHSN), which provides a standardized approach to surveillance methodology. Of the states with statutes requiring public reporting of HAIs, most have mandated the reporting of outcomes metrics, primarily catheter-associated bloodstream infections (CLABSIs) and various surgical site infections (SSIs). Some states have mandates regarding reporting of infections due to specific pathogens, most commonly methicillin-resistant Staphylococcus aureus (MRSA). Only a few states have mandated reporting of process metrics (e.g., percent of healthcare workers vaccinated against influenza). Adequate risk adjustment and data validity remain the primary problem with the HAI reports produced by states for healthcare consumers.

The impact of public reporting of HAIs on healthcare quality remains unknown.

What principles need to be adhered to for effective infection control?

There are ten assumptions on which public reporting of HAIs are predicated. From a public policy standpoint, all of these assumptions must be true for public reporting to be maximally effective. However, at the present time, most of the assumptions are either false or unproven. See Table I for these assumptions.

Table I.

Assumptions underlying mandatory reporting and public disclosure of HAI rates

1

Transparency, open exchange of information, and accountability are important societal values.

2

HAIs are preventable.

3

Valid data on HAI rates will be produced.

4

Consumers make rational decisions about choices in health care.

5

Consumers will understand and use data on HAI rates.

6

Consumers are able to choose their site of medical care and are willing to change their site of care if necessary.

7

Consumers who use HAI rate data will make decisions that will improve the quality of their care.

Overview of all important clinical trials, meta-analyses, case control studies, case series, and individual case reports related to mandatory public reporting of hospital acquired infections.

See Table II for a summary of the assumptions underlying the mandatory reporting and disclosure of HAIs, and the research that either supports or refutes these assumptions.

Table II.

Assumptions underlying mandatory reporting/disclosure of HAIs and studies that support or refute

Assumption

Validity of the assumption

Supporting or refuting data and/or studies

1

Transparency, open exchange of information, and accountability are important societal values.

True

There is a strong healthcare consumer movement in the US, driven in part by advocacy organizations (e.g., Consumers' Union)

2

HAIs are preventable.

TrueMany, but not all, HAIs are preventable

The Keystone Project, implemented in >100 Michigan ICUs, demonstrated that with a standardized approach to central line insertion, central line associated bloodstream infections (CLABSI) were reduced by approximately 2/3A systematic review of the literature determined that the proportion of reasonably preventable HAIs were:
CLABSI 65 to 70%Catheter-associated UTI 65 to 70%Ventilator-associated pneumonia 55%Surgical site infection 55%

3

Valid data on HAI rates will be produced.

At the present time, there are concerns that the data reported publicly are in many cases not valid; however, many states have not performed validity studies to assess this.

A retrospective cohort study at 4 medical centers comparing the performance of CLABSI surveillance by IPs to a computer algorithm found significant variation in IP surveillanceA validation study done in Connecticut found that IPs surveillance for CLABSI was only 48% sensitiveA retrospective review of 50 ventilated patients found application of the CDC definition for ventilator-associated pneumonia by IPs to be highly variableA study of three different VAP definitions found that all definitions performed poorly when compared to autopsy evidence of VAP

4

Consumers make rational decisions about choices in health care.

For elective procedures, consumers may or may not make informed choices about their healthcare

Patients rely on the recommendations of their physicians, family members and friends.
President Bill Clinton underwent coronary artery bypass graft (CABG) surgery at the hospital in the state of New York with the highest mortality rate for that procedure

5

Consumers will understand and use data on HAI rates.

It is not clear if consumers either understand HAI data or if these data are consistently applied to informed, medical decision making

Patients have a poor understanding of quality of care indicators, and this is worse in patients with low socioeconomic statusA significant proportion of the population does not have the reading proficiency to understand quality report cardsConsumers likely will not use indicators which they do not understandTwo recent reviews concluded that consumers rarely seek out this information and that it has a modest impact on medical decision-making

6

Consumers are able to choose their site of medical care and are willing to change their site of care if necessary.

Many patients are unable to choose their site of care due to their health insurance plan

A significant proportion of the population has little choice in healthcare venue or may have some choice that comes with financial penalty.
24% of Americans are enrolled in health maintenance organizations (HMOs) and 95% of covered workers are enrolled in a managed care plan (HMO, preferred provider organization or point-of-service plan)

7

Consumers who use HAI rate data will make decisions that will improve the quality of their care.

This assumption is valid only if the following underlying assumptions are correct:
Comparative data on hospital HAI rates are validHealthcare consumers can and will change their site of care in response to the reported data

The theoretical argument for the improvement of quality stems from the following potential responses to public reporting:
Remediation (hospitals make a concerted effort to improve quality)Restriction (licensing and accreditation organizations use the data to restrict provision of care by poor performers)Removal (poor performers discontinue providing services)Stimulation of competition between providers on the basis of improving quality in order to improve market share.

Data to support these claims are sparse and come from observational studiesFollowing mandatory public reporting of CABG surgery in New York State, a 21% reduction in CABG mortality was reported.
The decline in mortality may have been due to other factors, such as the avoidance of surgery on high risk patientsUnintended consequences of mandatory public reporting exist.
Some low volume surgeons with high mortality rates stopped performing CABGs after mortality rates were published

9

Positive outcomes will outweigh adverse unintended consequences.

Uncertain

Marshall et al., have described seven potential unintended consequences of public reporting on the quality of medical care:Tunnel vision. This occurs when quality improvement efforts are concentrated on areas being measured to the detriment of other important areas.Sub-optimization. This is pursuing narrow organizational objectives at the expense of strategic coordination.Myopia. Hospitals may concentrate on short-term issues and lose sight of the long-term outcomes.Convergence. Convergence is defined as placing more emphasis on being exposed as an outlier than on efforts to perform in an outstanding fashion.Ossification. This occurs when organizations avoid experimentation with new approaches out of fear of poor performance. .Gaming. Hospitals game the system when they alter behavior to gain strategic advantage. For example, quality indicators that are measured via administrative data can be affected by coached changes in the coding of diagnoses, since risk adjustment is dependent on the coding of co-morbid conditions.Misrepresentation. Public reporting may incentivize surveillance systems with suboptimal sensitivity.

10

Health care is a commodity.

In the United States, unlike many other countries, health care is treated as a commodity rather than as a basic human right

A large segment of the U.S. population is unable to purchase healthcare due to lack of resources.Public reporting of quality indicators stems from and reinforces the commodity concept.Persons unable to purchase healthcare will not benefit from mandatory public reporting of hospital acquired infections

Summary of the current controversies related to mandatory public reporting of hospital acquired infections and the respective arguments for each side.

To date, there is no definitive data to suggest that mandatory public reporting of hospital acquired infections results in improved infection prevention outcomes.

In theory, mandatory public reporting of hospital acquired infections should drive full or near full implementation, hospital wide, of known risk reduction practices. A recent report, however, suggests that significant challenges remain for effective implementation of risk reduction strategies. In a survey of California hospitals just prior to mandatory reporting of hospital acquired infections, variability was reported in infection prevention practices. Although 70% of hospitals reported full implementation of evidence based guidelines for the control of MRSA, 23% of hospitals reported not having adopted any infection control measures. Smaller, more rural hospitals were most challenged with implementation of infection risk reduction interventions.

The long term impact of mandatory public reporting of hospital acquired infections on infection prevention measures and outcomes remains undefined.

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